Right To Be Forgotten | Clanwilliam IRL

Before completing this form please ensure that by making this request you will not infringe on any of your medical or legal obligations.

Right To Be Forgotten Form

Account Number(Required)

GP/Pharmacy Name(Required)

Email(Required)

Phone(Required)

Patient Name(Required)

Patient Date of Birth(Required)

Patient Address(Required)

Signature(Required)

By typing your full name above, you are providing us with your digital signature, which is as legally binding as your physical signature. By filling in this form you are agreeing to be contacted by a member of the Support Team in order to progress this request.

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